<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173000694
Report Date: 09/06/2023
Date Signed: 09/06/2023 12:05:08 PM

Document Has Been Signed on 09/06/2023 12:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:KELSEYVILLE MIGRANT HEAD STARTFACILITY NUMBER:
173000694
ADMINISTRATOR:ADRIANA MENDOZAFACILITY TYPE:
850
ADDRESS:5081 A KONOCTI ROADTELEPHONE:
(707) 279-1022
CITY:KELSEYVILLESTATE: CAZIP CODE:
95451
CAPACITY: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 13DATE:
09/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Adriana MendozaTIME COMPLETED:
12:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/06/2023, Licensing Program Analyst (LPA), Sebastian Phouthaovong made an unannounced Case Management visit to follow up on an Unusual Incident Report (UIR) submitted to CCL on 08/25/2023. LPA met with Director, Andrea Mendoza and spoke with her the regarding UIR involving multiple children

During today's inspection, LPA toured the facility inside and out and observed 13 children being supervised by 5 staff members. LPA conducted interviews with the Director & 4 staff and received documents.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with facility representative, Andrea Mendoza

There were no Title 22 deficiencies cited during today's inspection.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1